Health Department Assessment Form
Please complete this form to help us assess and improve our health department services. Your feedback is valuable.
Full Name
*
First Name
Last Name
Department or Service Area Assessed
*
Please Select
Immunization Services
Maternal & Child Health
Environmental Health
Disease Prevention
Community Outreach
Other
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate the overall quality of the services provided?
*
1
2
3
4
5
Please rate the following aspects of the department:
*
Rows
Excellent
Good
Fair
Poor
Staff Professionalism
1
2
3
4
Timeliness of Service
5
6
7
8
Cleanliness of Facility
9
10
11
12
Clarity of Information
13
14
15
16
Was your concern or need addressed during your visit?
*
Yes
Partially
No
How likely are you to recommend this department to others?
*
Not likely
1
2
3
4
5
6
7
8
9
Very likely
10
1 is Not likely, 10 is Very likely
Select the age group of the person assessed
Please Select
Under 18
18-34
35-54
55-74
75 or older
Prefer not to say
What is your primary reason for visiting the department today?
Additional comments or suggestions
Submit Assessment
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